Recruitment of doctors to non-standard grades in the NHS: analysis of job advertisements and survey of advertisers

Introduction

The number of doctors in the United Kingdom who are appointed to hospital posts that don't conform to the standard NHS grades is rising, as trusts try to comply with restrictions on working hours in the NHS's “new deal” for doctors in training and the European Working Time Directive.1^–3 We define non-standard grade posts as non-consultant jobs that do not conform to the recognised hospital grades (box 1). Doctors appointed to non-standard grades–which tend to be described as though they are training grades–are usually called trust doctors, because they are employed on terms and conditions set by individual trusts. However, a variety of other job titles are used, such as hospital specialist, assistant surgeon, and clinical fellow registrar grade. Terms of employment and education are not standardised.

The actual number of doctors holding non-standard grade posts is not known, as the Department of Health does not include them in its annual census.1 However, an unsubstantiated statement in a recent health department report said that “separate analysis shows that there are around 5000 doctors on local contracts, for whom the national grade is unclear.”5

The problem with non-standard grade posts is that they can be confusing and may exploit doctors unfamiliar with the UK system. For example, time spent in non-standard posts cannot be counted towards basic specialist training.6 Some doctors may not realise that posts are not recognised training grade posts. Many of the job titles do not clearly convey the type of job the doctors will be doing. Also, applicants need to know where they will fit into the medical hierarchy; doctors holding such posts are seen as “lacking in status and recognition,” and there is a “feeling that they are overlooked in terms of professional development, study leave and discretionary points.”5

We investigated the proportion of advertisements for non-standard grade posts in BMJ Careers, the BMJ supplement that advertises almost all hospital posts in the United Kingdom. We also looked at the reasons why these posts exist, who fills them, and what the appointed doctors do.

Methods

To investigate the proportion of non-standard grade posts placed in BMJ Careers and the range of job titles advertised we took a random sample of eight issues published in the 12 months to 9 September 2002. We took two issues from each quarter, as the type of posts advertised may vary across the year. We compared all non-consultant job advertisements with the standard grades (box 1) and recorded the job titles for all the posts whose details did not meet the standard definitions (box 2).

We then surveyed advertisers to investigate why they were advertising non-standard posts, who they expected to fill these posts, and what they expected the post holders to do. For each new advertisement for a non-standard grade post published in the four issues of BMJ Careers from 11 January to 1 February 2003 we sent a questionnaire (see bmj.com) to the medical staffing officer responsible for the post. Most advertisers were contacted by post. We telephoned non-responders up to three times, and if they still didn't respond we sent the questionnaire again. Finally, the BMJ's editor and the director of BMJ Careers sent a letter to the chief executives of non-responding trusts requesting their help in ensuring that questionnaires were completed.

Results

Of the 4949 non-consultant jobs advertised in the random sample of eight issues of BMJ Careers published in 2001-2, 1150 (23%) did not conform to the standard NHS grades. In the four issues between 11 January and 1 February 2003, 430 (21%) of the 2073 non-consultant jobs advertised were for non-standard grades. We received 192 completed questionnaires (45%) from these advertisers.

Factors preventing recruitment to standard training grades–The most frequently reported reasons that respondents gave for their not being able to recruit to a standard grade were that there was no more funding from the deanery for approved posts (98 respondents (51%)) and that service needs could not be met by doctors in standard training grades (75 (39%)). Nineteen respondents (10%) said that the posts could be filled only by doctors with limited GMC registration.

Type of post–Of the 192 advertisements 161 (84%) were for substantive (non-locum) posts. Eighty five posts (44%) had been newly created. Twenty nine posts (15%) were advertised because the previous post holder had moved to a senior job, 16 (8%) because the previous post holder had moved to a junior job, and 57 (30%) because the previous post holder had left for other reasons. Fifty four (64%) of these new posts were created to fill gaps in service when doctors in training were unavailable.

On-call commitments–Of the respondents 132 (69%) said the post holder would be expected to take part in regular on-call duty, and 50 of these respondents said the on-call duty would be at least 1 in 5 (being on call for 24 hours every five days and one in five weekends).

Working level–Respondents expected that the non-standard grade doctors would work at the level of various standard grades: 41 (21%) said the post holder would share an on-call rota with consultants, 73 (38%) with specialist registrars, 80 (42%) with senior house officers, 30 (16%) with staff grade doctors, and eight (4%) with associate specialists.

Teaching commitments–Sixty three respondents (33%) expected their post holders to teach medical students, 38 (20%) to teach house officers, 26 (14%) to teach senior house officers, and three (2%) to teach specialist registrars. No teaching commitment was expected by 106 respondents (55%).

Educational needs–One hundred and sixty five respondents (86%) said a session would be allocated to the educational needs of the post holder, though 19 of these said they expected that the post holder would miss teaching time because of clinical commitments.

Recruitment from overseas–One hundred and thirty one respondents (68%) said they were expecting to recruit someone from a country outside the European Economic Area. Most respondents said they expected it was likely or very likely that the posts would be filled by doctors trained outside the United Kingdom (166 (86%)), by doctors coming to the United Kingdom for training (129 (67%)), or by doctors who had failed to find training posts (152 (79%)).

Discussion

Just under a quarter of non-consultant posts advertised in two different study periods were for non-standard grade posts. Half of such posts are created to meet service requirements when there is no more deanery funding for recognised training posts. More than two thirds of the doctors filling these posts are required to do on-call work, and a quarter are on call for 24 hours every five days and one in five weekends, or more frequently, breaching the European Working Time Directive. Most advertisers expect the posts to be filled by doctors from outside the European Economic Area.